clinical study treatment of hemorrhagic vocal polyps by...

Clinical StudyTreatment of Hemorrhagic Vocal Polyps by Pulsed DyeLaser-Assisted Laryngomicrosurgery

Hyung Kwon Byeon,1,2 Ji Hyuk Han,1,2 Byeong Il Choi,1,2 Hye Jin Hwang,1,2

Ji-Hoon Kim,1,2 and Hong-Shik Choi1,2

1Department of Otorhinolaryngology, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro,Gangnam-gu, Seoul 135-720, Republic of Korea2Institute of Logopedics and Phoniatrics, Yonsei University College of Medicine, Seoul, Republic of Korea

Correspondence should be addressed to Hong-Shik Choi; [email protected]

Received 8 January 2015; Revised 19 March 2015; Accepted 19 March 2015

Academic Editor: Adam Klein

Copyright © 2015 Hyung Kwon Byeon et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Objective. Conventional surgical techniques of laryngomicrosurgery (LMS) on hemorrhagic vocal polyps are often difficult dueto obscuration of the surgical field by inadvertent bleeding from the lesion, and there are often significant amounts of mucosalepithelium loss. Here, we introduce our surgical technique using pulsed dye laser (PDL), which can effectively resect the polyp withvocal fold mucosa preservation. Methods. Patients who were diagnosed with hemorrhagic vocal polyp and who were surgicallymanaged using PDL from March 2013 to October 2014 were retrospectively reviewed. Preoperative and postoperative clinicaloutcomes and surgical findings were evaluated. Results. A total of 39 patients were treated with PDL-assisted enucleation LMS.The average age was 43.7 years (range 20–73), and there were 20 males and 19 females (17 professional voice users). In all cases, thehemorrhagic polyp was successfully enucleated after application of PDL, thereby preserving the overlying epithelium. Postoperativevoice outcomes were favorable with clear preservation of the vocal fold mucosal wave. Conclusion. PDL-assisted enucleation LMSfor the treatment of hemorrhagic vocal polyps can be a safe and effective surgical technique. It can be considered a promisingtreatment option for hemorrhagic vocal polyps.

1. Introduction

Hemorrhagic vocal polyps are the most commonly encoun-tered benign lesions of the vocal fold. They are more oftenfound in men than in women and are usually located on theanterior two-thirds of the vocal fold [1, 2].Themain causativemechanism for hemorrhagic vocal polyps is acute or chronicmechanical phonotrauma to the microvasculature of thesuperficial layer of lamina propria (SLP).Thehyperfunctionalglottal sound production causes shearing stress, leading tocapillary bleeding within the SLP. The resulting malformedneovascularized mass can be easily ruptured, leading tohemorrhagic events within the vocal fold proper, whichin turn hinder normal propagation of vocal fold mucosalwaves and cause increased vocal effort. This creates furtherphonotrauma to the vocal fold, which eventually exacerbatesthe evolving polyp. The main involvement site is the SLP,

and the overlying mucosal epithelium is typically normal;however, the latter may also be involved, having either akeratotic appearance from increased frictional force betweenthe vocal folds or a mucosa-overabundant appearance fromthe volumetric expansion off the polyp within the SLP [3–5].

Conventionally, hemorrhagic vocal polyps are surgicallyresected either by the amputation technique using coldmicroinstruments or CO

2laser or by the subepithelial

microflap resection technique [6].The amputation techniqueresults in a significant amount of epithelial loss, especiallyif the polyp is broad-based, and postoperative vocal out-comes can be undesirable. Additionally, although CO

2laser

can achieve optimal hemostasis and improved precision, itfrequently results in mucosal scarring [7]. The transmittedheat energy from the CO

2laser inevitably affects both the

epithelium and the SLP, which can lead to fibrosis andincreased mucosal stiffness, thereby ultimately resulting in

Hindawi Publishing CorporationBioMed Research InternationalVolume 2015, Article ID 820654, 6 pageshttp://dx.doi.org/10.1155/2015/820654

2 BioMed Research International

deterioration of voice quality. In the subepithelial microflapresection technique, although the overlying epithelium israised by epinephrine-saline infusion, the operation canoften be cumbersome due to a certain amount of inevitablebleeding owing to the nature of the hemorrhagic polyp. The585 nm pulsed dye laser (PDL) is an angiolytic laser causingselective photothermolysis. The chromophore of the PDL isoxyhemoglobin, resulting in the laser inducing photocoagu-lation of microvascular lesions with minimal damage to thesurrounding normal tissue. Based on our recent successfulreports of PDL application in treating sulcus vocalis andglottic leukoplakia [8, 9], we havemanaged to use PDL in sur-gically removing hemorrhagic vocal polyps. This study aimsto report our surgical technique, PDL-assisted enucleationlaryngomicrosurgery (LMS), which can effectively resect thepolyp with vocal fold mucosa preservation.

2. Methods

2.1. Patients. This study was conducted on 39 patients whowere admitted and received PDL-assisted enucleation LMSunder general anesthesia for hemorrhagic vocal polypsdespite persistent conservative treatment at the Departmentof Otorhinolaryngology, Gangnam Severance Hospital, fromMarch 2013 to October 2014. Inclusion criteria of the patientswere as follows: (1) pathologically proven hemorrhagicvocal polyps and (2) evident hemorrhagic vocal polyps onpreoperative videostrobolaryngoscopy (Laryngograph Ltd.,London, UK). Exclusion criteria were as follows: (1) simple,nonhemorrhagic vocal polyps and (2) other accompanyingstructural vocal fold abnormalities. All patients providedwritten informed consent before the surgery, and the Institu-tional ReviewBoard of Yonsei University College ofMedicineapproved this retrospective study.

2.2. Surgical Technique. All operations were performed solelyby the senior author (Hong-Shik Choi). Each step of the oper-ation is illustrated (Figure 1). After clearly exposing the lesionunder suspension laryngoscopy, the 585 nm PDL (CynosureInc., Chelmsford, MA, USA) was applied above the polyp,thoughwithout direct contact (450𝜇s pulse width, 2.0 J/pulsemaximum output, and 2Hz repetition rate). The PDL wasdelivered via a 0.6 mm flexible fiber with a constantly deliv-ered energy of 0.75 J/pulse, and an average of 20 pulses (range8–49) was applied for each vocal polyp. After confirming theblanching change of the overlying epithelium, an incisionwasmade, and, with careful dissection, the epithelium could beeasily “peeled away” from the polyp lesion. Further dissectionwas performed with microinstruments, and eventually onlythe polyp was extracted, leaving the overlying epitheliumunharmed. The epithelium was repositioned carefully tocover the surgical defect, and the operation was completed.Following the operation, the patients were prescribed strictvoice rest for 7 to 10 days and were also counseled on vocalhygiene and behavioral vocal changes.

2.3. Clinical Outcome Assessment. For evaluation of treat-ment outcomes, all patients were given voice assessments and

laryngeal stroboscopic examinations before and two monthsafter the operation. Voice analysis including aerodynamicmeasures (Phonatory Aerodynamic System; KayPENTAX,Montvale, NJ, USA), acoustic analysis, and electroglotto-graphic analysis (EGG) (Lx speech studio program; Laryngo-graph Ltd., London, UK) was conducted, and voice handicapindex (VHI) was examined. Auditory perceptual judgmentwas carried out in a recorded sample called “autumn” [10],which was approximately twominutes in length, with the useof theGRBAS scale (G, grade; R, roughness; B, breathiness; A,asthenia; S, strain).The recorded samples were evaluated in ablinded manner by two speech pathologists. The point scaleof each category was 0 to 3 points, and themean of two valueseach obtained from two speech pathologists was used for theanalysis. The patients were followed up for a minimum of 4months to a maximum of 9 months until it was consideredthat there was no need for further followup.

The demographic, clinicopathological, and treatmentcharacteristics were retrospectively reviewed and analyzed.The following voice parameters were evaluated: maximumphonation time (MPT), mean airflow rate (MFR), subglot-tic pressure (Psub), closed quotient (CQ), irregularity offrequency percentage (CFx), irregularity of amplitude per-centage (CAx), average fundamental frequency (F0), noise-to-harmonic ratio (NHR), jitter percentage, and shimmerpercentage. Preoperative and postoperative results of eachvoice parameter were statistically compared using paired 𝑡-test with SPSS 18.0 software for Windows (SPSS, Chicago, IL,USA), with statistical significance defined as a 𝑃 value lessthan 0.05.

3. Results

Themean age of the studied population was 43.7 years (range20–73 years), and there were 20males and 19 females. Amongthese patients, 17 (43.6%) were professional voice users. Thehemorrhagic vocal polyp was located on the right vocal foldin 17 patients, on the left in 19, and on both in 3 patients.

All operations were successfully accomplished with-out any significant intraoperative complications. There wasalmost no bleeding during each operation, and after removalof the polyp, there were minimal amounts of mucosal loss(Figure 1). Preservation of the mucosal wave was noted in allcases on postoperative stroboscopic examination (Figure 2).During the follow-up period of the patients, there wasno recurrence of the polyp or any other laryngeal lesiondevelopment.

Changes of each voice parameter after the operationare summarized in Table 1. VHI score and GRBAS scalescores from auditory perceptual judgment showed significantimprovements after the operation. Other objective measuresof voice analysis showed a general improvement, but only sig-nificant differences were noted in MFR and jitter percentage.

4. Discussion

The normal vocal fold is composed of five layers: theepithelium, the three layers of the lamina propria (superficial,

BioMed Research International 3

(a) (b)

(c) (d)

(e) (f)

Figure 1: Intraoperative view of pulsed dye laser- (PDL-) assisted enucleation laryngomicrosurgery. (a) After suspension laryngoscopy undergeneral anesthesia, a hemorrhagic vocal polyp is noted on the right vocal fold. (b) The PDL is delivered by a 0.6 mm fiber (arrow), whichis held directly over the surface of the hemorrhagic polyp. The treated portion of the vocal fold can be confirmed by the blanching changeof the epithelium. (c) After the PDL application, a longitudinal incision is made at the overlying epithelium. (d) The epithelium is easilypeeled off from the lesion and opened using a small cotton ball mounted on microforceps. (e) After careful dissection with appropriatemicroinstruments, the hemorrhagic polyp is easily enucleated out using microcurved alligator forceps. (f) The remaining epithelium isrepositioned after removal of the lesion.


(a)

(b)

Figure 2: (a) Preoperative laryngeal stroboscopic images. A typical hemorrhagic vocal polyp with a sessile base is noted on the left vocal fold.(b) Laryngeal stroboscopic images taken two months after the operation. Notice the preservation of the mucosal wave.

intermediate, and deep), and the thyroarytenoid muscle.According to Hirano’s cover-body theory of vocal fold vibra-tion, the epithelium and the SLP constitute the “cover,” thevocalis muscle acts as the “body,” and the intermediate anddeep layers of the lamina propria, which make up the vocalligament, are the “transition” layer [11]. The cover layer isconsidered important, as it is mainly involved in the normalmucosal wave vibration of the vocal folds. The basementmembrane zone (BMZ) is a collection of extracellular matrix(ECM) that attaches and secures the overlying epitheliumand the SLP underneath. The BMZ is further divided intotwo distinct layers, the superficial lamina lucida (LL) andthe deep lamina densa (LD). The LL connects the basalepithelium by hemidesmosomes, and the LD is attached tothe SLP by anchoring fibers consisting of collagen type VII.The LL and the LD are bound by anchoring filaments madeof collagen type IV and fibronectin [12]. Hemorrhagic vocalpolyps are known to develop from phonotrauma such assevere voice abuse or misuse, and these benign vocal foldlesions can lead to acute or persistent dysphonia or hoarse-ness. Its main pathogenesis is microvascular trauma within

the BMZ and the SLP. Although some hemorrhagic vocalpolypsmay resolve spontaneously withminimal or conserva-tive treatment [13], surgery is the standard treatment of choicefor persistent polyps after voice therapy and observation.

A PDL beam with a 585 nm wavelength is selectivelyabsorbed by hemoglobin, and the energy from the laserbeam penetrates the superficial epithelium without causingdamage yet results in intravascular coagulation of subep-ithelial microvasculature. The laser was initially adoptedin dermatologic clinics to treat port-wine stains, telangiec-tasias, and any other cutaneous vascular lesions. Recently,the PDL has generated substantial interest in the field ofphonosurgery for treating various laryngeal lesions. Sincethe initial attempt of McMillan et al. of applying PDLin treating laryngeal papillomas [14, 15], there have beennumerous reports of PDL application in the managementof leukoplakia, glottic dysplasia, granuloma, and vascularabnormalities of the vocal folds [16–19]. The utility ofthe PDL has been further verified with the treatment ofglottic hyperkeratosis and sulcus vocalis by Choi et al.[8, 9].

BioMed Research International 5

Table 1: Voice quality improvement after the operation.

Preoperative Postoperative 𝑃 valueAerodynamic measures, mean (SD)

MPT (sec) 12.43 (5.73) 14.35 (5.50) 0.084MFR (L/sec) 0.16 (0.13) 0.11 (0.09) 0.005∗

Psub (cmH20) 6.80 (2.08) 6.23 (2.28) 0.287EGG analysis, mean (SD)

CQ (%) 42.42 (5.45) 42.91 (8.06) 0.728CFx (%) 12.50 (10.89) 9.54 (6.83) 0.197CAx (%) 6.86 (3.41) 6.35 (4.60) 0.515

Acoustic analysis, mean (SD)𝐹0 (Hz) 158.62 (38.14) 157.21 (41.61) 0.630NHR 0.15 (0.03) 0.14 (0.02) 0.121Jitter (%) 2.33 (1.58) 1.50 (0.87) 0.006∗

Shimmer (%) 4.55 (2.92) 3.70 (1.61) 0.134Patient-perceived satisfaction, mean (SD)

VHI score 40.82 (28.62) 13.96 (13.50) <0.001∗

Auditory perceptual judgment, mean (SD)G 1.32 (0.54) 0.63 (0.46) <0.001∗

R 0.57 (0.40) 0.26 (0.38) <0.001∗

B 0.86 (0.48) 0.37 (0.32) <0.001∗

A 0.03 (0.19) 0 (0) 0.326S 0.32 (0.36) 0.18 (0.24) 0.004∗

IQR: interquartile range; MPT: maximum phonation time; MFR: meanairflow rate; Psub: subglottic pressure; CQ: closed quotient; CFx: irregularityof frequency; CAx: irregularity of amplitude; 𝐹0: average fundamentalfrequency; NHR: noise-to-harmonic ratio; VHI: voice handicap index; G:grade; R: roughness; B: breathiness; A: asthenia; S: strain.∗ refers to the values that are statistically significant (𝑃 value < 0.05).

The photoangiolytic effect of the PDL can greatly facilitatethe operation, not only from improved hemostasis, but alsodue to the induration effect of the lesion. From the results ofthis study, the hemostasis could control the natural bleedingtendency of the hemorrhagic vocal polyp, thereby avoidingany troublesome obstruction of surgical view with bleeding.Additionally, we observed that the lesion became relativelyhardened due to the photocoagulation caused by the PDL,which further aided in the manipulation and dissection ofthe polyp. Essentially, there are three fundamental effectsof laser on living tissue: photoacoustic, photothermal, andphotochemical effects. According to the ultrastructural eval-uationmade by Ayala et al., the photoacoustic and photother-mal effects of the PDL create a cleavage plane, specificallybetween the LL and LD of the BMZ [20]; thus, the PDLtreatment would cause the mucosal epithelium to separateand elevate above the lesion within the polyp-containingvocal fold. Therefore, from this effect, not only could theepithelium be easily “peeled off” from the surface of thepolyp, achieving enhanced precision of cold instrumentaldissection and selective extraction of the polyp, but the all-important cover layer of the vocal fold could also be preservedwith appropriate wound healing, allowing the reestablish-ment of normal mucosal wave vibration and phonation afterthe surgery. From the results of the laryngeal stroboscopicexaminations (Figure 2), favorable postresection mucosal

pliability and glottal closure could be verified in all cases,and voice assessment results showed general improvement ofvoice quality following the surgery (Table 1). There has beenan earlier report by Zeitels et al. of treating the hemorrhagicvocal polyp by an angiolytic laser after raising a subepithelialmicroflap with saline solution infusion [19]. Our specifictechnique goes one step further, exploiting not only thephotocoagulative effect of PDL but also the cleavage planeformation effect created by the laser. The application ofPDL as an initial step of the surgery omits the necessity ofsubepithelial infusion.

Given that PDL is easy to use and is a safe and effi-cacious tool for laryngeal lesions, it has been incorporatedas a minimally invasive technique for use in office-basedprocedures [17, 21]. The so-called “awake” PDL technique fortreating vocal polyps does not require resection; however, itmay lead to repeated procedures and a longer postoperativerecovery period. It may also present certain limitations due tothe constant movements of the larynx in conscious patients.The procedure described in the present study, however, isperformed under general anesthesia and can be consideredas one particular method of LMS utilizing a PDL as aneffective surgical tool. It may be a useful, alternative surgicaltechnique to the conventional surgical resection of hem-orrhagic vocal polyps by subepithelial microflap elevationfollowed by subepithelial infusion of saline and epinephrineas initially reported by Hochman and Zeitels [6]. Althoughfurther investigation with a longer period of follow-up and alarger volume of patientsmay be required to establish the fea-sibility of the PDL-assisted enucleation LMS technique, thisprocedurewas found to be effective in removing hemorrhagicpolyps and was easy to perform. It has also shown promisingpostoperative results with a decreased period of healing.

5. Conclusion

The PDL-assisted enucleation LMS technique can be easilyand effectively performed to treat hemorrhagic vocal polypsindicated for surgery. The mucosal wave of the vocal fold iswell preserved as postoperative healing is improved, resultingin good voice outcomes. This surgical technique may alsoprove to be a valuable treatment for various laryngeal lesions.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

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